The nurse is collecting data from a caregiver, and the caregiver states that the child has had a “strawberry-colored tongue.” The nurse recognizes this as a manifestation of which disorder?
Hemophilia.
Congestive heart failure.
Kawasaki disease.
Rheumatic fever.
The Correct Answer is C
Choice A reason: Hemophilia causes bleeding issues, not a strawberry tongue, which is a mucosal symptom. Kawasaki disease’s characteristic tongue appearance matches the description, making this unrelated and incorrect compared to the specific disorder associated with the child’s reported tongue manifestation in the assessment.
Choice B reason: Congestive heart failure affects cardiac function, not oral mucosa, and doesn’t cause a strawberry tongue. Kawasaki disease is the condition linked to this symptom, making this irrelevant and incorrect for the nurse’s recognition of the child’s tongue appearance in data collection.
Choice C reason: A strawberry tongue, with a red, bumpy appearance, is a hallmark of Kawasaki disease, often seen with fever and rash. This aligns with pediatric infectious disease criteria, making it the correct disorder the nurse recognizes based on the caregiver’s description of the child’s tongue.
Choice D reason: Rheumatic fever may cause oral symptoms but not a classic strawberry tongue, which is specific to Kawasaki disease. The latter’s mucosal findings are distinctive, making this less accurate and incorrect compared to identifying Kawasaki disease as the cause of the tongue manifestation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Discussing care options involves clinical judgment, which is the nurse’s responsibility, not delegable to family. Providing comfort tasks like swabs or pads is appropriate, making this incorrect, as it involves professional decision-making unsuitable for family delegation in the adolescent’s care.
Choice B reason: Keeping medical equipment like a blood pressure cuff involves monitoring, a nursing task, not delegable to family. Comfort tasks like providing swabs or pillows are suitable, making this incorrect, as it requires clinical skills beyond family’s role in the terminally ill adolescent’s care.
Choice C reason: Supplying mouth swabs for lip moistening is a simple comfort task family can perform, promoting involvement and patient comfort. This aligns with pediatric palliative care delegation, making it a correct intervention to delegate to family for the terminally ill adolescent’s care.
Choice D reason: Providing disposable pads for hygiene is a non-clinical task family can manage, supporting dignity and comfort. This aligns with family involvement in palliative care, making it a correct intervention to delegate for the terminally ill adolescent’s care in the hospital setting.
Choice E reason: Supplying pillows for repositioning is a comfort-focused task family can handle, enhancing the adolescent’s well-being. This aligns with pediatric palliative care principles, making it a correct intervention to delegate to family members for the terminally ill adolescent’s hospital care.
Correct Answer is D
Explanation
Choice A reason: Assuming fear of pregnancy may misinterpret the 12-year-old’s concerns, potentially shutting down dialogue. Asking about worries invites her to share specific fears, making this presumptive and incorrect compared to the nurse’s role in exploring the child’s feelings about menstruation openly.
Choice B reason: Suggesting fear of pain narrows the conversation, missing other possible concerns like embarrassment or myths. Asking about worries allows broader exploration, making this limiting and incorrect compared to the nurse’s approach to understanding the girl’s specific fears about getting her period.
Choice C reason: Dismissing the child’s fear by calling periods “good” may invalidate her feelings, discouraging openness. Asking about worries validates concerns, making this dismissive and incorrect compared to the nurse’s role in fostering a supportive dialogue about menstruation with the 12-year-old.
Choice D reason: Asking what the child has heard about periods encourages her to express specific worries, facilitating education and reassurance. This aligns with pediatric nursing communication principles, making it the most appropriate response to address the 12-year-old’s concerns about menarche during the check.
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